WASHINGTON -- In a new letter report to the U.S. Department of Health and Human Services, the Institute of Medicine provides guidance for state and local health agencies and health care facilities regarding the standards of care that should apply during disaster situations.Public health emergencies and catastrophic events -- such as a pandemic or an unforeseen disaster like an earthquake or bioterrorism -- can make conventional standards of care impossible to uphold due to overwhelming numbers of patients and shortages in equipment, medicine, and staff.States must develop consistent policies and protocols for crisis standards of care to prepare for disasters in which thousands -- or hundreds of thousands -- of individuals become gravely ill and suddenly seek medical treatment.

"Health care workers pride themselves on giving optimal treatment to all their patients, and are obliged by law and professional ethics to use a high standard of care," said committee chair Lawrence O. Gostin, associate dean and the Linda and Timothy O'Neill Professor of Global Health Law, GeorgetownUniversity. "However, in a public health emergency, dedicated professionals simply will not have the capacity to deliver this same high level of care.The health care system will collapse without a rational plan that includes ethical allocation of limited resources and that is seen by the public as transparent and fair. Perhaps most importantly, states must offer dedicated professionals protection against legal liability when they conscientiously make clinical decisions that are necessary to save lives and preserve the public's health."

According to the committee that wrote the report, crisis standards of care, which involve substantial changes to health care operations and the level of care it is possible to deliver, are put into place out of necessity in response to a disaster situation. Under such circumstances, failing to adopt crisis standards of care -- which include guidance on conserving, substituting, adapting, and doing without resources -- is likely to result in greater death, injury, or illness. Crisis standards-of-care policies and protocols ensure the best health care possible, given the resources at hand.

Some state and local health agencies have made considerable strides in developing crisisstandards-of-care policies and protocols, but many have only just begun to address this need. Following the national guidelines recommended by the committee would help ensure states develop protocols within an ethical framework so they are consistent, and would allow coordination and fair allocation of resources during a disaster.Consistency in developing and implementing crisis standards of care is needed between all levels of government and especially between neighboring jurisdictions.

The ethical precepts of medicine still apply during a disaster.Health care professionals must provide the best care they reasonably can to each patient.In conditions of overwhelming resource scarcity, however, clinicians are ethically justified to perform some actions that would not be acceptable under normal circumstances, such as allotting resources to provide treatments preferentially to those patients most likely to benefit. The standards governing health care during a disaster must be seen as fair by both patients and providers, the report says, and health care decisions and implementation must be equitable and transparent.Stakeholders in the community and in the health care professions should be engaged in developing and evaluating local crisis standards of care.

Stronger legal protections are needed for health care providers forced to make difficult decisions during disasters.State health agencies should be legally empowered to institute crisis standards of care in affected areas, and incentives should be in place to support health care providers responding to an emergency, such as legal protections for practitioners and institutions.

This study was sponsored by the U.S. Department of Health and Human Services.Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.A committee roster follows.